UNITED STATES BANKRUPTCY COURT WESTERN DISTRICT OF NEW YORK _____________________________________________________________________________________________________________________________ In Re: Case No.: Chapter: Debtor(s) SSN: xxx-xx_____________________________________________________________________________________________________________________________ Part I APPLICATION TO PAY FILING FEE IN INSTALLMENTS (INCLUSIVE OF ADMINISTRATIVE FEE & TRUSTEE FEE) In accordance with Bankruptcy Rule 1006, application is made for permission to pay the filing fee in installments. The number of installments shall not exceed four (4) and the final installment shall be payable not later than 120 days after the filing of the petition. I propose the following terms for payment. $ _________________with the filing of the petition, or on or before _____________________________, and the balance in payments of $_____________ by _________________________ , $_______________ by __________________________, and $______________ by _____________________________. I certify that I have not paid any money or transferred any property to an attorney or any other person for services in connection with this case or in connection with any other pending bankruptcy case and that I will not make any payment or transfer any property for services in connection with the case until the filing fee is paid in full, and I CERTIFY THAT I AM UNABLE TO PAY THE FILING FEE IN FULL UPON THE FILING OF THIS PETITION FOR THE FOLLOWING REASON(S): ________________________________________________________________________________________________________________________ __________________________ Dated _________________________________________ Signature of Applicant ________________________________________ Signature of Applicant I certify that I have discussed with the debtor(s) his or her inability to pay the filing fee except in installments, and the supporting reason(s) for that inability is true and accurate to the best of my knowledge. __________________________ _______________________________________________ Dated Signature of Attorney ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Part II DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION (See 11 U.S.C. §110) I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. §110; (2) I prepared this document for compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §110(b), 110(h), and 342(b); (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. §110(h) setting a maximum fee for services chargeable by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required under that section; and (4) I will not accept any additional money or other property from the debtor before the filing fee is paid in full. ___________________________ Dated __________________________________________________\SS#xxx-xx-______________ Signature of Bankruptcy Preparer If more than one person prepared this document, attach additional signed sheets conforming to the appropriate form for each person. A bankruptcy petition prepare’s failure to comply with provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. §110; 18 U.S.C. §156. Part III ORDER IT IS ORDERED that the debtor pay the filing fee in installments on the terms set forth in the foregoing application. IT IS FURTHER ORDERED that until the filing fee is paid in full the debtor shall not pay, and no person shall accept, any money for services in connection with this case, and the debtor shall not relinquish, and no person shall accept, any property as payment for services in connection with this case. IT IS FURTHER ORDERED THAT IF THE FILING FEE IS NOT FULLY PAID BY THE CLOSE OF BUSINESS ON ________________________ THIS CASE SHALL BE DISMISSED WITHOUT THE NEED FOR FURTHER COURT ORDER. IT IS FURTHER ORDERED that should the debtor default on the payments or the case is dismissed prior to the payment of the filing fee in full, the unpaid balance is due the Court prior to the filing of a subsequent petition. An Order to Show Cause will be issued requiring the personal appearance of the debtor(s) and counsel and may result in the dismissal of this case. IT IS ORDERED that the application to pay the filing fee in installments has been denied due to the debtor(s) default on payments of the filing fee in a previous bankruptcy case(s), case number ______________________and that the debtor(s) shall have until the close of business on ________________________________to pay the filing fee in full or an Order to Show Cause will be issued to have the case dismissed for failure to pay the filing fee prescribed by 28 U.S.C. §1930(a)(1)-(a)(5). _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ and that the debtor(s) shall have until the close of business on ________________________________to pay the filing fee in full or an Order to Show Cause will be issued to have the case dismissed for failure to pay the filing fee prescribed by 28 U.S.C. §1930(a)(1)-(a)(5). ____________________ Date (07/11) _____________________________________ [SELECT ONE] United States Bankruptcy Judge American LegalNet, Inc. www.FormsWorkFlow.com